The Role of Medicine ; Dream, Mirage, or Nemesis?

219 Pages·1980·4.978 MB·English

by  Thomas McKeown

The Role of Medicine
DREAM, MIRAGE
OR NEMESIS?

THE ROLE OF
MEDICINE
DREAM, MIRAGE OR NEMESIS?
Thomas McKeown
PRINCETON UNIVERSITY PRESS
Copyright © Thomas McKeown 1979
Published by Princeton University Press, Princeton, New Jersey
All Rights Reserved
Clothbound editions of Princeton University Press books are
printed on acid-free paper, and binding materials
are chosen for strength and durability
Typeset by Cotswold Typesetting Ltd., Gloucester
Printed in the United States of America by
Princeton University Press, Princeton, New Jersey
CONTENTS
Preface to the second edition vii
Introduction xi
PART ONE. CONCEPTS OF HEALTH AND DISEASE
1 Evolution of Health Concepts 3
2 Inheritance, Environment and Disease 12
PART TWO. DETERMINANTS OF HEALTH
3 Decline of Mortality 29
4 Infectious Diseases 45
5 Non-infective Conditions 66
6 Health in the Past 71
7 Health in the Future 79
8 Medical Achievement . 91
PART THREE. THE ROLE OF MEDICINE
9 Non-Personal Health Services 117
10 Clinical Services 131
11 Medical Education 143
12 Medical Research 156
13 Dream, Mirage or Nemesis? 176
14 Medicine as an Institution 190
v

PREFACE TO THE SECOND EDITION
The writer of a controversial paper published in a medical journal soon
discovers that those who agree with him write to the author while those
who disagree write to the editor. Something of the same kind can be
observed in the reception of a controversial book, so that the opposition
often appears to be wider and warmer than in fact it is. I do not think
I am mistaken in believing that most readers of The Role of Medicine
were in general agreement with its conclusions, although with so large
and complex a theme inevitably there were reservations on certain
points, not all of them minor.
However, some people interpreted the book as an attack on clinical
medicine, and one or two linked it with Illich’s Medical Nemesis. A close
reading is not required to show that the two books have little in com­
mon, except perhaps in the sense that the Bible and the Koran could be
said to be identified by the fact that both are concerned with religious
matters.
But as ‘the more violent the emotions generated by a topic, the
harder it is to be rational about it’,1 I should like to remove misunder­
standings by clarifying my own viewpoint.
1. I believe that for most diseases, prevention by control of their
origins is cheaper, more humane and more effective than intervention by
treatment after they occur. As an interpretation of the past this state­
ment is rapidly becoming a platitude; as a prediction for the future I
recognize it is still arguable.
2. There are no grounds for criticism of medicine in the fact that
medical education, research and practice are based on quite different
premises. In their assumptions about the determinants of health, doctors
have been under the same misapprehensions as everyone else.
3. The conclusion that medical intervention is often less effective
than has been thought in no way diminishes the significance of the
clinical function. When people are ill they want all that is possible to be
done for them and small benefits are welcome when larger ones are
not available. Moreover, inability to control the outcome of disease
does not reduce the importance of the pastoral or Samaritan role of
the doctor. In some ways it increases it.
1. Haldane, J. B. S., Science and Life (London: Pemberton, 1968), p. 65.
vii
Preface to the Second Edition
4. Finally, and on a more personal note, let me add that I do not belong
to the small minority of saints, reformed sinners and others for whom
physical discomfort is necessary for mental comfort, and if I were ill I
should not turn to fringe medicine, acupuncture, transcendental medi­
tation or faith-healing. I should like good medical attention, by which
I mean clinical service which combines technical competence with
humane care.
Since writing The Role of Medicine I have become aware of defici­
encies which seemed to justify the preparation of a second edition.
Some are related to points raised by reviewers, others to issues which
I think I now see more clearly than when I first wrote. The following
are among the most important of them.
When assessing the relative importance of different influences on
health in the past, I based conclusions on the decline of mortality and
made only a brief reference to the treatment of morbidity. This ap­
proach was rightly said to underestimate the contribution of clinical
intervention, and in a new chapter I have tried to make a more ade­
quate appraisal of medical achievement by considering also postpone­
ment of death (from a specific cause) and treatment of non-fatal illnesses.
While most people are agreed about the interpretation of the past,2
some have questioned my extrapolation to the future: the suggestion
that, as in the case of the infections, most non-communicable diseases
are more likely to be controlled by removing their causes rather than
by intervening in disease mechanisms. I have tried to narrow the area
of disagreement by separating diseases into four classes: relatively in­
tractable ; preventable, associated with poverty; preventable, associated
with affluence; and potentially preventable, not known to be related to
poverty or affluence. It is only in the fourth class that there are likely
to be considerable differences of opinion about the most effective
approach.
I have also considered carefully the suggestion that the conclusion
that the main influences on health - nutrition, environment and behav­
iour - are outside the medical care system has little bearing on the role
of medicine.3 Here I believe it is important to distinguish the role of
2. I share reservations about the reliability of certification of cause of death but
they do not affect my main conclusions.
3. ‘The major question is to what extent the assessments of The Role of Medicine
should change the kind of care that the able and conscientious physician gives his
patient. Not very much, I think.’ Ingelfinger, F.J., New EnglandJournal of Medicine,
296 (1977), p. 449.
Vlll
Preface to the Second Edition
medicine as an institution from its more limited responsibility for
clinical care. I have suggested that in its larger role, medicine should be
concerned with all the influences on health, a conclusion that has a con­
siderable bearing on medical education and research as well as on health
services. But if medical intervention is often less effective than most
people, including most doctors, believe, there is also a need for more
critical evaluation of clinical procedures before they are introduced,
and for greater emphasis on personal care of the sick (the pastoral role
of the doctor). For the large number of patients (among the retarded,
the mentally ill and the aged sick) who provide no scope for active
measures, the last aim is unlikely to be achieved without a reshaping
of health services, particularly hospital services.
I should not like to end this Preface without expressing my indebted­
ness to my colleague, Professor R. G. Record. We have worked to­
gether for thirty-three years, and I have discussed with him nearly every
point relating to medical achievement and population growth. If I have
been able to avoid serious errors in this wide and treacherous subject,
it has been due largely to his sound advice. I am also most grateful to
Professor A. G. W. Whitfield who has been kind enough to read care­
fully the revised edition.
It is a pleasure for me to thank Mrs Eileen Armstrong and my
secretary, Mrs Wendy Greenaway, for the care they have taken with
the preparation of the typescript.